The gladiator of the Indian public health sector

By Aarthi Kannan 

Armed with innovation, the Indian public sector is set to bolt ahead. What are the challenges that befuddle its path? - Dr. Srinath Reddy shares his vision with Aarthi Kannan in this interview

We have come a long way since the drafting of our constitution, which highlights our right to health and dignity - a time when our ancestors grappled with a multitude of deadly infectious diseases. Amongst the most notorious was polio, which crippled tens of thousands of children each year. The Universal Immunization program won a long and fierce battle against polio with India being declared polio-free in 2014. This story is just one amongst the several milestones India has crossed. From government-led health financing schemes to breast-milk banking for neonates in Rajasthan, public health has recently witnessed many innovations. However, not all is milk and honey in India’s public health sector. We shoulder on against several hardships - tuberculosis, malnutrition and infant mortality being only the tip of the iceberg. Our public health financing is dishearteningly amongst the lowest in the world - 1.4% of our GDP(1). To bring to light the key challenges and developments in the public health sector in the past decade, Dr. Srinath Reddy, President, Public Health Foundation of India (PHFI), shares his vision 2020 in this interview.

Dr. Reddy completed his medical graduation from Osmania Medical College and went on to pursue MD in Medicine and Cardiology super-specialization at AIIMS, New Delhi. During his years of successful practice as head of Cardiology at AIIMS, he developed an eagle’s eye perspective of healthcare, which transformed him into an eminent public health professional. He is an adjunct professor of epidemiology at Harvard University and member of the WHO Advisory Panel on Cardiovascular Diseases. He received the Padma Bhushan award for his contributions in 2005. His knowledge and passion in public health are evident in his belief that the future of Indian healthcare lies in universal health coverage, aligning central and state schemes, up scaling health workforce, strengthening our public health system and its governance; development of appropriate technology and domestic self-reliance in drug production. PHFI was launched in 2006 and functions under Dr. Reddy’s presidency as a foundational framework to create institutions delivering multi-disciplinary learning to improve population health.

Reflecting on the past decade : developments in India’s public health

Commending the increase in non-physician healthcare providers and community health workers which has accelerated the decline in maternal mortality and under-5 child mortality, Dr. Reddy also enthuses about the surge in point-of-care diagnostics, artificial intelligence (AI) and information technology (IT) which are bridging gaps in quality of healthcare and its access.

“Various health-financing schemes initiated by central and state government provide greater access and partial-cost coverage for hospitalized healthcare in vulnerable populations. India’s health workforce has been up scaled in number and skill to meet critical gaps in our healthcare. Artificial intelligence (AI) is helping develop diagnostic and management algorithms for diabetes and cardiovascular disease. Point-of-care diagnostic devices are moving healthcare closer to people’s homes. Molecular biology and gene therapies are raising new hopes for cancer cure and chronic diseases.”

Challenges

“Low levels of public financing for health, inadequately developed public procurement systems, ill-defined regulatory systems are key barriers for implementations of innovations. Quantitative and qualitative deficiencies in the health workforce limit their uptake and appropriate use on a large scale. Additionally, diagnostic and management algorithms must be developed based on our datasets and population characteristics rather than blindly applying algorithms developed for Western population”, he states.

AI : A double edged sword

“AI can be useful but also selectively misleading. While adding diagnostic and management skills and speed, it can also erode core values of compassionate care that recognizes and respects the individuality of each person.” A strong advocate for privacy, humane and integrative facets of healthcare, Dr. Reddy asserts that great care must be taken to prevent impersonal, tunnel-vision care of fellow human beings.

India’s place on the global healthcare map - Water, water everywhere; nor any drop to drink

“Our tertiary care facilities in large metros can match the world’s best in service quality but we also have many areas of poor performance in public health healthcare system and primary care, tier two/three cities, smaller towns which place India in a low rank globally. We cannot advertise medical tourism and deny access to many Indians who need it. We boast of being a global pharmacy, but a large number of Indians are impoverished by expenditure on medicines”

As of 2016, 64.5% of overall health spending is out-of-pocket, primarily outpatient care and medicines. A 2018 PHFI study revealed that 38 million Indians were impoverished between 2011 and 2012 by out-of-pocket expenses on medications alone. The 2018 Competition Commission of India report clarifies that 50 to 65% Indians do not have regular access to essential medicines, despite over 40% of the Indian pharmaceutical industry’s $33-billion worth of drugs being exported. While proponents of our medical tourism might adulate India on affordable healthcare, the 71st Round of National Sample Survey Organization argues that 85.9% of rural households and 82% of urban households in India have no access to healthcare insurance/assurance.

The future: Unlocking the potential of Indian healthcare

“I view healthcare as a service and not as an industry which regards returns of investment in monetary terms”. Dr. Reddy proposes a strong commitment to the protection, promotion and restoration of health at population and individual levels. “We must aim to reduce gaps in health equity in our geographically, culturally and socio-economically diverse population and emulate the commitment to health equity reflected by Scandinavian countries, UK, Canada, Japan, Thailand, South Korea and Cuba.”

He envisions appropriate AI application in population-based and personalized health interventions; molecular biology-guided diagnostics and therapies, greater deployment of technology-enabled non-physician healthcare providers and greater levels of home-care and self-care in the future.

“Areas needing empowerment are continuity of care for chronic conditions, reducing physician-dependency through nurse-practitioners and physician-assistants, patient-centric healthcare with patient and family-led decision-making, strengthening regulations to ensure clean water, sanitation, unadulterated and healthy food. Public policy and public financing are critical catalysts that can strongly mobilize healthcare. A responsive public sector, a responsible private sector and a resourceful voluntary sector can together do wonders to uplift our health system.”